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Knowledge Translation for Employment Research SEDL - VCU
KTER Center Technical Brief #6 – August 2015
Highlights from a KTER Center Systematic Review: Employment Interventions for
Return to Work in Working Aged Adults Following Traumatic Brain Injury
This technical brief presents the findings and implications for Employment Interventions
for Return to Work in Working Aged Adults Following Traumatic Brain Injury (TBI): A
Systematic Review, [http://www.campbellcollaboration.org/lib/project/241/], submitted to
The Campbell Collaboration in January 2015. It is co-authored by Carolyn W. Graham,
Michael D. West, Jessica Bourdon, and Katherine Inge of Virginia Commonwealth
University. The review was supported by the SEDL Center on Knowledge Translation
for Employment Research (KTER Center), which is funded by the National Institute on
Disability, Independent Living, and Rehabilitation Research (NIDILRR).
The review was designed for the use of these KTER Center audiences: vocational
rehabilitation and other employment support professionals, researchers, policymakers,
businesses/employers, and people who experience TBI.
Background on Employment Following TBI
TBI occurs when an external force causes an alteration to brain function, such as loss of
consciousness, memory loss, and neurologic defects. TBI can occur by a blow to the
head, blast waves from an explosion, swift acceleration or deceleration, or the
penetration of a foreign object into the brain (Maas, Stocchetti, & Bullock, 2008; Menon,
Schwab, Wright, & Maas, 2010). TBI levels of injury range from mild to severe.
Increased level of brain injury severity is typically related to greater degree of
impairment post-injury. However, even individuals experiencing mild brain injuries can
experience problems in one or more areas of functioning.
Individuals who sustain a TBI often have difficulties in either obtaining competitive
employment or maintaining employment as a result of the post-injury difficulties that
they exhibit (Andelic, Stevens, Sigurdardottir, Arango-Lasprilla, & Roe, 2009; Ruttan,
Martin, Liu, Colella, & Green, 2008). Reported unemployment rates of people with TBI
have ranged from 45% to 78% (Doctor, Castro, Temkin, Fraser, Machamer, & Dikmen,
2005; Kendall, Muenchberger, & Gee, 2006), and tend to vary by such factors as
severity of the injury, the nature and extent of post-injury impairments, and the age and
level of education of the individual at the time of the injury.
Rehabilitation services following TBI focus on assisting individuals to adjust to their ongoing impairments and re-enter their communities, workplaces, schools, etc. Post-acute
interventions may, but not always, include vocational rehabilitation (VR). In the U.S., the
primary sources of return to work (RTW) interventions are employer disability
management programs and state VR agencies; other countries have equivalent
organizations (United Nations World Health Organization & The World Bank, 2011).
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Some of the specific approaches that may be used in returning adults with TBI to work
are Employee Disability Management Programs, transitional programs, supported
employment, job accommodations, adaptive devices, and assistive technology, and
ancillary therapeutic services. This review examined the effectiveness of rehabilitation
interventions on return to work (RTW) outcomes of adults with TBI. The goal of this
project is to provide information that will inform the target audiences regarding the
effectiveness of these rehabilitation employment interventions.
Interventions and Study Participants
Studies for this review were identified by using 15 databases (Article First via
FirstSearch, Australia Education Index/Australian Council for Educational Research,
CIRRIE – Center for International Rehabilitation Research Information and Exchange
Database, www.ClinicalTrials.com, Cochrane Central Registry of Controlled Trials,
ebrary: Academic Complete Collection, EBSCOhost Research Database, Google
Scholar, MEDLINE/PubMed, NARIC REHABDATA, ProQuest, PsycExtra, PsychINFO,
Science Direct, and Web of Science). Grey papers (i.e., unpublished or unavailable
through scientific databases) were also searched. We also hand searched reference
lists of papers included in the analysis and previous systematic reviews concerning
RTW, employment, and TBI.
Studies were included if they used interventions that assist working age adults with TBI
to return to competitive employment. Competitive employment was used as the
outcome measure because it represents optimal rehabilitation expectations. Our
definition of competitive employment had three criteria: (1) work tasks performed in an
integrated setting with co-workers who are predominantly non-disabled, (2) wages paid
by the business or organization where the work was performed (not by a disability
organization), and (3) wages commensurate with non-disabled co-workers having
similar qualifications and performing similar duties. Studies had to include the primary
outcome, employment status, and could include secondary outcomes such as earnings,
hours worked, and job tenure. Studies must have included participants who were
between the ages of 18 and 65 years of age who experienced a non-penetrating TBI,
engaged in either full-time or part-time employment at the time of injury, and were
unemployed or on medical leave at time of receipt of intervention. The TBI could have
been injured on or off the job. Studies that included mixed disabilities were included only
if information was provided separately for TBI participants. Finally, data had to have
been presented separately for competitive employment from the non-competitively
employed participants. The designs of studies included were either randomized
controlled trials (RCTs) or quasi-experimental designs. The comparison groups could
consist of treatment as usual, other appropriate interventions, or no intervention.
Results of the Review
Three RTW intervention randomized controlled trials with people with TBI were found.
No significant difference in effect was found among the studies (p = 0.81). All three used
different interventions: residential, holistic treatment group versus in-home rehabilitation
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program, 3-D artificial intelligence virtual reality training versus psycho-educational, and
CogSMART plus supported employment versus enhanced supported employment.
Below is a description of the studies.
1. Salazar et al., 2000: The Salazar et al. (2000) study was a randomized controlled
trial that was conducted with 120 active duty military service persons who had acquired
a moderate to severe traumatic brain injury. Most participants obtained TBI through
motor vehicle/traffic incident, assault, and alcohol-related accidents. The mean loss of
consciousness was 35 hours. All participants were within 90 days of injury. Participants
in the study were randomly assigned to the treatment group or the control group. Each
group had a separate treatment team from the other and the treatment teams worked
independently. There were periodic reviews of the treatment teams in order to maintain
fidelity to each treatment protocol.
Residential, Holistic Treatment Group. The 67 participants assigned to the residential,
holistic treatment group received eight weeks of intense residential cognitive
rehabilitation program. Their mean age was 24.7 years, 93% were male, 69% were
White, 24% were African American, and the race of the remaining 7% was "other not
specified." All had moderate to severe TBI with the mean Glasgow Coma Scale (GCS)
of 9.4.
The residential, holistic treatment program consisted of a team of interdisciplinary
practitioners including a physiatrist, neuropsychologist, occupational therapist, speech
pathologist, and rehabilitation assistants. The physical therapist, psychiatric and
neurological experts were consulted when needed. The participants in the group were
expected to follow military standards and a structured daily routine. The structured daily
routine consisted of physical fitness training, and group and individual therapies.
Therapies included cognitive, psychotherapeutic, pragmatic speech, community reentry, and integrated work programs.
In-Home Intervention Control Group. The 53 participants assigned to the in-home
without VR intervention control group received a limited home rehabilitation program.
Their mean age was 26 years, 96% were male, 70% were White, 17% were African
American, 11% were Hispanic, and 2% were Native American. All had moderate to
severe TBI with a mean GCS of 9.5.
The in-home rehabilitation program included TBI education and individual counseling
provided by a psychiatric nurse who made weekly 30-minute phone calls to each
participant. Educational materials and strategies to improve cognitive and organizational
skills were given to participants. This included training participants in number and card
games, encouraging return to physical exercise, suggesting participants watch
newscasts and read. They were also expected to resume daily physical fitness training.
No participants in this group received vocational or work rehabilitation.
All study participants were evaluated at 6, 12, and 24 months on RTW, psychosocial,
and interdisciplinary tests. Of the 67 participants in the treatment group, 60 (90%)
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returned to work, whereas 50 of 53 (94%) participants in the control group returned to
work. Thus, participants in the residential program experienced a better RTW outcome,
with the odds ratio being 0.514.
2. Man et al., 2013: The Man RCT was conducted with 50 participants who had mild to
moderate TBI recruited from Hong Kong hospitals and rehabilitation facilities. Man did
not report the cause of TBI. Inclusion criteria required participants to have a loss of
consciousness of less than six hours. There was no report of mean length of loss of
consciousness for either group. However, the GSC was used to assess severity of TBI
and the mean score on this scale was 10.25 (SD = 1.51; Range = 9-14) for the artificial
intelligent virtual reality-based vocational training system (AIVTS) (treatment group) and
10.05 (SD = 1.31; Range= 9-13) for the psycho-educational vocational training system
(PEVTS) (control group). No time since injury information was reported.
Fifty participants were randomly assigned either to the treatment or the control group.
Each group began with 25 participants. Both groups had similar informational content
but the training platform differed by group.
AIVTS Treatment Group. The AIVTS group received 12 sessions using 3-D artificial
intelligence virtual-reality-based training software program. The program begins the
training by determining the skill level of the participants. As the participant progresses
through training, the program can upgrade, maintain, or downgrade the training level to
meet the training needs of the participant based on participant performance. Therefore,
when participants performed well, the program would increase difficulty. If the
participant’s performance declined, the program would revert back to previous level of
training.
PEVTS Control Group. The PEVTS group also received 12 training sessions with
similar problem solving tasks, content, and structure given by a vocational trainer. Using
a manual designed for the intervention, the trainer provided instruction, time to practice
skills, and games on problem solving. Four trained rehabilitation professionals assessed
fidelity of intervention administration. The fidelity agreement intra-class coefficient was
0.645, p = 0.021.
Although authors referred readers to a demographic table, the table referred to did not
contain demographic information. Forty (20 per group) had three follow-up reports of
employment outcome at 1, 3, and 6 months. Primary outcomes related to cognition
were measured by the Tower of London test, the Wisconsin Card Sorting Test (WCST),
and the Vocational Cognitive Rating Scale (VCRS). Employment outcomes were
measured by participants' status in four categories: full-time employment, supported
employment, sheltered employment, and unemployed/unable to return to work. No other
employment measures were reported.
In order to compare studies, unemployment and sheltered workshop categories were
considered unemployed since sheltered workshop is not competitive employment.
Further no participants were in the sheltered workshop group. Supported employment is
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considered competitive employment and was included in the employment group. Of the
20 participants in the AIVTS group that were assessed at follow-up, 17 (85%) were
unemployed and 3 (15%) were employed at one month, 14 (70%) were unemployed
and 6 (30%) employed at three months, and 12 (60%) were unemployed and 8 (40%)
were employed at six months. Of the 20 participants in the PEVTS group that were
assessed at follow-ups, 20 (100%) were unemployed and 0 were employed at one
month, 16 (80%) unemployed and 4 (40%) were employed at three months, and 16
(80%) were unemployed and 4 (40%) were employed at six months. More of the AIVTS
group was employed than the PEVTS (odds ratio of 2.667).
3. Twamley et al., 2014: The Twamley RCT was conducted with 50 veterans with mild
to moderate TBI from Operation Enduring Freedom and Operation Iraqi Freedom. All
participants in both groups received supported employment for one year. Twenty-five
were randomly assigned to the Supported Employment with Cognitive Symptom
Management and Rehabilitation Therapy (CogSMART, treatment group) and 25 to
Enhance Supported Employment group (control). Twamley did not report on the cause
of the injury. No means of GCS were reported. Each group had separate employment
specialists. Both groups adhered to standardized procedures with a 0.90 adherence
rate.
CogSMART Treatment Group. The mean loss of consciousness was 6.5 hours and time
since most recent TBI was 4.08 years (SD = 2.78) for the CogSMART treatment group.
The majority of participants in this group were men (96%). Thirty-six percent of
participants identified as Hispanic (36%) and 24% percent of the treatment group
identified as White. No other race was reported. The mean age of participants in the
treatment group was 29.68 years (SD = 6.05) and the mean educational level was 12.88
(SD = 1.27).
The first three months of the intervention, the treatment group received one hour of
CogSMART and one hour of supported employment per week for the first three months
and then one hour of supported employment for the rest of the year. CogSMART
addressed post-concussive symptoms, prospective memory, attention and vigilance,
learning and memory, and executive functioning (see cogsmart.com for more
information).
Enhanced Supported Employment Control Group. The mean loss of consciousness was
1.0 hour for the control group, the enhanced supported employment group. Time since
most recent TBI was 5.04 years and the mean length of loss of consciousness across
last four traumatic brain injuries was 1 hour for this control group. As in the treatment
group, 96% of participants were men and 36% participants identified as Hispanic. Fortyeight percent of this control group was White. No other race was reported. The mean
age of participants was 33.84 years (SD = 7.89) and the mean of educational level was
14.00 (SD = 1.80) for the control group.
The control group received two hours of supported employment for the first three
months and then one hour of supported employment for the rest of the year. This group
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was given the supported employment intervention “to control for non-specific
therapeutic factors provided in CogSMART” (Twamley et al., 2014, p. 62).
Participants were assessed at six and 12 months post treatment. Each group lost four
participants during the course of the study or at follow-up, which left each group with 21
participants each. There was no difference in competitive employment at 12 months
with both groups having 13 (52%) participants being employed. Thus, CogSMART did
not improve the odds of employment for the treatment group. The supported
employment sessions that each group received may have contributed to this lack of
difference. Further research with three groups: CogSMART only, CogSMART plus
supported employment, and supported employment only needs to be conducted to
understand better the specific effects of each approach.
Conclusion
The findings from this review are consistent with prior TBI RTW studies that emphasize
the importance of early intervention following TBI (as in the residential holistic models)
and in-vivo training and support in the natural work setting (as in the supported
employment model) in maximizing RTW outcomes. These interventions are not mutually
exclusive, but can be effective as compatible components of TBI rehabilitation. The
findings are also consistent with prior reviews of the TBI RTW literature, which have
found that the interventions provisionally appeared to be effective but that caution
should be used in using this information due to sample size and lack of study
replication. Further, two of the studies used military samples and findings may not
generalize to civilian populations. These reviews called for higher quality of
rehabilitation intervention studies to be conducted to determine accurately whether
these interventions were effective. More randomized controlled trials using these
interventions (including studies with civilian populations) are needed to assess the
strength of evidence for these interventions.
References
Andelic, N., Stevens, L. F., Sigurdardottir, S., Arango-Lasprilla, J. C., & Roe, C. (2009).
Associations between disability and employment 1 year after traumatic brain
injury in a working age population. Brain Injury, 26, 261-269. doi:
10.3109/02699052.2012.654589
Doctor, J. N., Castro, N. R., Temkin, N. R., Fraser, R. T., Machamer, J. E., & Dikmen, S.
S. (2005). Workers’ risk of unemployment after traumatic brain injury: A normed
comparison. Journal of the International Neuropsychological Society, 11, 747752.
Kendall, E., Muenchberger, H., & Gee, T. (2006). Vocational rehabilitation following
traumatic brain injury: A quantitative synthesis of outcome studies. Journal of
Vocational Rehabilitation, 25, 149-160.
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Maas, A. I. R., Stocchetti, N., & Bullock, R. (2008). Moderate and severe traumatic brain
injury in adults. Lancet, 7, 728-741.
Man, D. W. K., Poon, W. S., & Lam, C. (2013). The effectiveness of artificial intelligent
3-D virtual reality vocational problem-solving training in enhancing employment
opportunities for people with traumatic brain injury. Brain Injury, 27, 1016-1025.
doi: 10.3109/02699052.2013.794969
Menon, D. K., Schwab, K., Wright, D. W., & Maas, A. I. (2010). Position statement:
Definition of traumatic brain injury. Archives of Physical Medicine and
Rehabilitation, 91, 1637-1640. doi: 10.1016/j.apmr.2010.05.017
Ruttan, L., Martin, K., Liu, A., Colella, C., & Green, R. E. (2008). Long-term cognitive
outcome in moderate to severe traumatic brain injury: A meta-analysis examining
timed and untimed tests at 1 and 4.5 or more years after injury. [Supplement 2]
Archives of Physical Medicine and Rehabilitation, 89, S69-S76. doi:
10.1016/j.apmr.2008.07.007
Salazar, A. M., Warden, D. L., Schwab, K., Spector, J., Braverman, S., Walter, J., …
Ellenbogen, R. G. (2000). Cognitive rehabilitation for traumatic brain injury: A
randomized trial. Journal of American Medical Association, 283 (23), 3075-3081.
Twamley, E. W., Jak, A. J., Dean, C. D., Bondi, M. W., Lohr, J. B. (2014). Cognitive
symptom management and rehabilitation therapy (CogSMART) for veterans with
traumatic brain injury: Pilot randomized controlled trial. Journal of Rehabilitation
Research & Development, 51(1), 59-70.
United Nations World Health Organization & The World Bank (2011). World Report on
Disability. Retrieved from: http://www.who.int/disabilities/world_report/2011/en/
--About the KTER Center: The Center on Knowledge Translation for Employment
Research (KTER Center) aims to identify the best available evidence related to the
employment of Americans with disabilities and investigate why and how individuals use
(or do not use) research evidence. The KTER Center contributes to a better
understanding of how research evidence can most effectively be translated into new or
improved policies, employment opportunities, and support systems.
Learn more about the KTER Center: www.kter.org
Available online: www.kter.org/ktactivities/dissemination#tb
Alternate formats of this Technical Brief are available upon request to:
800-266-1832 or 512-391-6517 (voice)
KTER@sedl.org (Email)
This is a product developed by the Center on Knowledge Translation for Employment
Research through grant #H133A100026 to SEDL from the National Institute on
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Disability, Independent Living, and Rehabilitation Research (NIDILRR) in the U.S.
Department of Health and Human Services (HHS), Administration for Community Living
(ACL). However, these contents do not necessarily represent the policy of the U.S.
Department of HHS, and you should not assume endorsement by the Federal
Government.
SEDL, an affiliate of American Institutes for Research, and its partner in this work,
Virginia Commonwealth University (VCU), are Equal Employment Opportunity/
Affirmative Action Employers committed to affording equal access to education and
employment opportunities for all individuals. Neither SEDL nor VCU discriminates on
the basis of age, sex, race, color, creed, religion, national origin, sexual orientation,
marital or veteran status, political affiliation, or the presence of a disability.
Copyright © 2015 by SEDL, an Affiliate of American Institutes for Research